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Oppose Global Vaccine Apartheid

The case for vaccinating the globe is evident — millions of lives are more important than pharmaceutical profits or intellectual property rights. Rishab Chawla In the Fall of 1884, representatives from thirteen European nations and the United States met to develop a plan to seize and divvy up the content of Africa for imperial gain. What ensued was decades of violent domination, occupation, and pillaging of natural resources in what was dubbed the “Scramble for Africa.” The colonization of indigenous people and seizure of their land has severely affected the social and economic development of their countries, with significant implications for contemporary global health. Indeed, superimposing a map of the history of colonialism on top of a map of global COVID-19 vaccine distribution would more or less yield one image. As of May 1, over half the world’s countries have vaccinated less than 1% of their populations, ten of which have yet to vaccinate a single person. Also, 75% of vaccine doses have gone to a tiny handful of countries, a trend that is expected to continue with high- and upper-middle income countries having procured contracts to 6.3 billion out of 8.9 billion reserved doses. While the US can vaccinate its entire population multiple times over, millions of predominantly Black and Brown people in the Global South are not expected to be vaccinated until as late as 2024. The disturbing inequities in the number of vaccine doses administered largely stem from stringent intellectual property (IP) rules implemented at the World Trade Organization (WTO) in the 1990s that restrict access to life-saving medications. The WTO agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) requires all member countries to guarantee drug companies monopoly control over the public research and technology used to produce pharmaceuticals and forbids generic production. Essentially, TRIPS was designed to anchor the economic standing of low- and middle-income countries to an inescapable IP regime. At the October 2020 Council on TRIPS meeting, India and South Africa introduced a proposal — supported by 100+ countries — calling for a temporary waiver in order to scale up local generic production of vaccines, but the US and select other countries have blocked it. Since then, 10 US Senators and hundreds of organizations* including Public Citizen, OxFam, Human Rights Watch, Justice is Global, and Physicians for Human Rights have called on President Biden to remove patent protections and commit to a people’s vaccine. To divert these grassroots demands, Western philanthropic parties including the Gates Foundation have touted the WHO’s COVAX scheme, which is projected to vaccinate ~20% of the population of participating countries by the end of the year. However, it is has to date supplied under 50 million doses and is not operating at a fast enough pace to reach global herd immunity. Though a welcome and crucial initiative, COVAX ultimately preserves the power differential between the Global North and South and entrenches reliance on charity over self-determination. The growing movement for a people’s vaccine, in contrast, calls for justice at the point of production, not just distribution. Critics of relieving IP restrictions claim that it is an ineffectual gesture because the main barriers lie in manufacturing capacity, not patents. But data compiled by Knowledge Ecology International (KEI) tells a very different story through current vaccine manufacturing capacity of several countries' facilities, many of whom are in queue for case-by-case negotiations with pharmaceutical manufacturers and would be able to scale up production if they had the blueprint or technical knowledge. Bangladesh-based company Incepta, for example, is on standby to make hundreds of millions of doses pending approval from Moderna, Johnson & Johnson, or Novavax. Proponents of a people’s vaccine acknowledge the shortage of raw materials in the most impoverished nations and do not see freeing up patents as the only goal. Rather, it is only the first step. In the 1990s and 2000s, the Treatment Action Campaign and allied groups organized mass global actions to make HAART and anti-fungal drugs available to patients with HIV/AIDS in South Africa. Not only did they successfully pressure Pfizer to supply fluconazole to clinics at a sharply reduced price, but their efforts led to unprecedented investments in public health infrastructure and expansion of services. A similar feat can and must be done again. The longer the SARS-CoV-2 virus is allowed to replicate, the greater its potential to mutate and increase in transmissibility. Most recently in India, a new variant has emerged and been linked to several countries, owing to India’s devastatingly high daily caseload of now over 400,000. This pandemic knows no borders, none of us are truly safe until all of us are safe.We must not accept a new normal in which COVID-19 becomes a relic of the Global North, but becomes endemic to the most resource-strapped pockets of the Global South. As medical students, many of us were fortunate to be vaccinated as early January, and soon after had the opportunity to volunteer to vaccinate our communities. But we may feel powerless knowing that we cannot quite reach the arms of billions who are in dire need of a dose. The global drive to vaccinate the world has likewise called for alliances between academic institutions and on-the-ground health justice activists. We all have a role to play in ensuring that governments and pharmaceutical companies place people over profit and make available the fruits of massive public investment. It is time to roll up our sleeves once more and get to work. Please add your name to the following: https://secure.phr.org/secure/vaccine-equity
https://freethevaccine.org/why-sign-on/
https://actionnetwork.org/forms/send-a-postcard-to-the-white-house Stay up to date with ongoing advocacy efforts: https://peoplesvaccine.org/
https://freethevaccine.org/
https://justiceisglobal.org/trips-waiver-week-of-action *Conspicuously absent in this list is the American Medical Association, which has not yet made a public statement on the topic. My team has introduced a resolution to be heard at the June 2021 annual meeting calling on the AMA to take immediate action in support of a people’s vaccine. If you are an AMA-MSS member, you can add your testimony here until 05/10/21. The views expressed are those of the author alone and do not represent those of his institution.

A Call to End the World’s Worst Humanitarian Crisis: Yemen

Sara Al-Zubi, Kei McHale, Leah Sarah Peer, Laasya Vallabhaneni, Brett Nelson We are students at Harvard Medical School and faculty at Massachusetts General Hospital concerned about the rapidly deteriorating humanitarian situation in Yemen, currently exacerbated by the COVID-19 pandemic and the continued Saudi-led blockade. This letter is in direct support of the Yemenis that are fighting in opposition of the blockade and the destruction of Yemen’s healthcare system, and is intended to underscore the dire need for the international community, and particularly the Global Health community, to take action. Since the inauguration of Joseph R. Biden as the 46th President of the United States, there has been growing interest in renewing diplomatic efforts to end the war on Yemen. Over the past six years, the U.S. has directly contributed to the prolongation of the war and humanitarian catastrophe that has resulted from it, including through the sale of billions of dollars worth of military arms to Saudi Arabia, some of which have been directly involved in the massacre of Yemeni children. It is crucial, now more than ever, that the American government implement diplomatic and humanitarian solutions to end the war on Yemen. The Yemeni war began in 2015 and has evolved into a multi-state war on a global scale. Even prior to the war, Yemen was already the poorest and most underdeveloped Arab country. At present, 17.8 million Yemenis lack access to safe water and sanitation. This is in addition to the 19.7 million people that lack access to adequate healthcare. Since the beginning of the world’s worst humanitarian crisis, 233,000 civilian lives have been lost, including the lives of more than 3,000 children. Due to the war and coalition airstrikes, there has been extensive destruction of the Yemeni healthcare infrastructure. The Yemen Data Project estimates that nearly 31% of the coalition airstrikes have struck civilian sites. Between March 2015 and March 2020, 281 airstrikes hit schools and universities, 241 airstrikes hit civilian cars and buses, 134 airstrikes have struck water and electricity sites and 83 have hit medical facilities. Not only so but these airstrikes are occuring at approximately 11 per day and nearly a quarter of the victims have been women and children. Currently, 400,00 children in Yemen may die from famine, which translates into 1 child every 75 seconds dying in Yemen [1]. In addition to political turmoil and a stagnant economy, the Yemeni people are now faced with a rapidly worsening healthcare crisis, stemming from a lack of healthcare facilities and supplies, a shortage of healthcare providers, and extremely high rates of food insecurity. All of these factors have been exacerbated by the COVID-19 pandemic, the effects of which have been unparalleled. The London School of Hygiene and Tropical Medicine’s research model predicts that up to 11 million people in Yemen could become infected, with between 62,000 and 85,000 deaths by mid-2021 [1]. This would result in a fatality rate of 28% among Yemenis with COVID-19 -- a rate more than five times higher than the global average [1]. According to the International Rescue Committee, Yemenis have experienced a 30% decrease in income since the start of the pandemic, all while dealing with a 68% increase in the cost of essential commodities such as food [5, 6]. Our Demands: The Saudi-led coalition’s offensive military operations in Yemen must end immediately to prevent further loss of life. Based on the history of U.S. involvement and the extent of the humanitarian crisis in Yemen, it is critical for American organizations and healthcare professionals to support policies and initiatives to address key health elements of the problem. We, therefore, urge the Biden Administration to end political and military collaboration with the Saudi-led coalition to enforce accountability for attacks on civilians and humanitarian aid workers, as follows: Applying pressure on Saudi Arabia to lift the blockades on all ports of entry to Yemen, including air, sea, and land, to allow the unrestricted entry of food, medicine, and other essential goods, as well as the full resumption of civilian air travel [7]. Withdrawing from hostilities and expressly prohibiting any further U.S. assistance or support, including intelligence sharing, logistics support activities, and other destabilizing activities in Yemen, to any members of the Saudi-led coalition [8]. Considering congressional action to cut off arms sales to members of the Saudi-led coalition, either of certain categories of weapons or completely [8]. Institute sanctions to hold Saudi Arabia accountable for its human rights abuses and devastating restrictions on humanitarian access to Yemen [8]. Furthermore, we urge all concerned parties to support an immediate end to the war on Yemen, as follows: Health professional associations in the U.S. should adopt resolutions opposing the war and the blockade imposed by the Saudi-led coalition on Yemeni ports of entry. Public health practitioners should increase awareness in their own professional organizations of the humanitarian effects of U.S. collaboration with the Saudi-led coalition blockade on Yemen and urge these groups to take a stand in opposition to it by organizing symposia and panel discussions including Yemeni and Yemeni-American health professionals, supporting written research and policy briefs on the subjects, and hosting fundraisers. Health professionals and public health practitioners, especially those with an understanding of the policy environment, should reach out to their representatives in Washington to express concern about the healthcare crisis in Yemen and to advocate for the use of diplomacy to end the Saudi blockades and Saudi-coalition air-strikes that are having a deleterious effect on Yemen’s healthcare infrastructure. As part of our work through 3Sisters Foundation, we have created a Yemen Health Toolkit to highlight ways health communities can be involved in the advocacy efforts of Yemen. The humanitarian crisis in Yemen is worsening by the day, and the time is now for Public Health professionals to speak up against it. Join us on Tuesday, April 27th at 6:00 pm EDT on Zoom for a Yemen Health Humanitarian Crisis Panel sponsored through the Harvard Physicians for Human Rights Chapter in collaboration with 3Sisters Foundation, Inc. References 1. https://www.telegraph.co.uk/news/2021/03/12/one-child-dying-every-75-seconds-yemen-brink-biggest-famine/ 2. medglobal.org/wp-content/uploads/2020/07/A-Tipping-Point-for-Yemen%E2%80%99s-Health-System072020.pdf 3. news.un.org/en/story/2020/12/1078972 4. https://us16.campaign-archive.com/?u=1912a1b11cab332fa977d3a6a&id=e0562bce18 5. https://www.amnesty.org/en/latest/campaigns/2018/03/saudi-arabia-should-invest-in-human-rights-not-pr-campaigns/ 6. https://www.rescue.org/press-release/covid-19-makes-yemens-hunger-and-economic-nightmareworse-each-day-irc-calls 7. www.hrw.org/report/2020/09/14/deadly-consequences/obstruction-aid-yemen-during-covid-19 8. http://www.gard.no/web/content/yemen-port-situation 9. https://www.justsecurity.org/63855/getting-past-the-veto-on-ending-yemen-war-how-congress-next-move-can-succeed/

Call to Action: Vaccine Equity in Israel-Palestine

By Asmaa Rimawi, Anand Chukka, and Lianet Vazquez We are students at Harvard Medical School concerned about the state of health in the Palestinian territories, currently exacerbated by the COVID-19 pandemic and Israel’s inequitable distribution of vaccines. This letter is in direct response to claims by faculty at our medical school, American public health professionals, and the mainstream media that Israel’s vaccination campaign is a successful example of COVID vaccine distribution. This positive portrayal of Israel’s vaccination campaign is misleading. While Israel has vaccinated 49% of its citizens, five million Palestinians who live under Israel military occupation or blockade have not been included in its vaccination campaign and will have to wait months for vaccines (1) . Physicians for Human Rights-Israel, along with 14 other Israeli, Palestinian, and international health and human rights organizations have called on Israel to provide the necessary vaccines to Palestinian healthcare systems (2). Under the 4th Geneva Convention and international human rights law, Israel is obligated to provide healthcare and meet sufficient public health standards in the occupied territories. The Israeli government has claimed that vaccination responsibilities fall with the Palestinian Authority (PA), the limited self-governing body, as part of a 5-year interim agreement (3). The PA, however, maintains only limited rule of certain parts of the West Bank and is dependent on international humanitarian aid, as well as tax revenue collected by Israel on its behalf. Israel maintains full civilian and military control of 61% of the West Bank, where Israeli settlers, who enjoy full civil liberties and rights under Israeli law, are receiving COVID vaccines transported by specialized, refrigerator-equipped vans. Their Palestinian neighbors living a few kilometers away under Israeli military rule have not received these COVID vaccines by virtue of being Palestinian. Amnesty International has declared that these vaccine disparities add to the mounting evidence of Israel’s institutionalized discrimination (4). The devastation resulting from the COVID-19 pandemic and the ensuing disparities in pandemic response and vaccine distribution has been exacerbated in the Gaza Strip, the densely populated territory administered by the Palestinian Authority that has been under Israeli and Egyptian land and sea blockade for the past 13 years. Since then, Israel has waged three large-scale military campaigns that have left the territory’s healthcare infrastructure in shambles, with rebuilding efforts limited by the blockade. Electricity cuts have prevented Gaza’s ICUs from caring for COVID patients and others and would make storing a vaccine difficult if it were available. The continual gutting of Gaza’s healthcare system has resulted in a surge in COVID cases with limited testing capabilities and ICU beds (4). In addition to refusing to vaccinate civilians within Gaza, Israel has also directly blocked the entry of 2,000 vaccines acquired by the Palestinian Authority for front-line healthcare workers in Gaza (5). By virtue of its 13-year blockade of the Gaza Strip, and the subsequent devastation of the territory’s healthcare infrastructure, Israel is obligated to make vaccines available to Palestinians in the strip and to assist them in their pandemic response. In our time at Harvard Medical School, we have been taught that a healthcare system that purposely prioritizes citizens based on race, religion, or ethnicity cannot be deemed a successful healthcare model, and that metrics such as equity are critical in assessing a healthcare system. Given the devastation that this pandemic has wrought on Palestinian communities living under Israeli military occupation or blockade, and Israel’s failure to meet its responsibilities as an occupying power under international law, we call our own medical school and others to stand in solidarity with the Palestinian people by demanding that Israel equitably distribute its supplies of the COVID-19 vaccine. We reiterate the following articulated asks of Israel made in a joint statement by human rights organizations in Israel-Palestine(6): Provide a quantity and timeline of vaccines for the Palestinian people Ensure that the vaccines that are distributed are of equal quality and standardization as those given to Israeli citizens and Israeli settlers of the West Bank. Provide and ensure a ‘cold chain’ infrastructure is set-up to allow for sustainable delivery of the COVID-19 vaccine Provide full financial support of the Palestinian Authority’s initiative to distribute the COVID-19 vaccine End the blockade and occupation of the Palestinian Territories and work to rebuild previously damaged healthcare infrastructure. Sources 1: https://www.bbc.com/news/world-middle-east-56143126 2:https://www.phr.org.il/en/israel-must-provide-necessary-vaccines-to-palestinian-health-care-systems/ 3:https://www.middleeasteye.net/news/vaccination-apartheid-gaza-struggling-covid-19-infections-israel-rolls-out-jab 3:https://reliefweb.int/report/occupied-palestinian-territory/denying-covid-19-vaccines-palestinians-exposes-israel-s 4:https://www.middleeasteye.net/opinion/coronavirus-gaza-population-2-million-available-intensive-care-beds-26 5:https://abcnews.go.com/Health/wireStory/palestinians-israel-blocks-shipment-vaccines-gaza-75909889 6:https://www.btselem.org/press_releases/20210105_joint_statement_israel_must_provide_vaccines_to_palestinians

PHR: Violent Political Insurrectionists Must be Held Accountable

Below is an excerpt from a statement by Donna McKay, PHR's executive director, in response to the insurrection at the United States Capitol on Wednesday, January 6: We condemn this violent and abhorrent assault on the rule of law. These terrorizing acts incited by President Trump and perpetrated by a mob of insurrectionists are an assault on the right to free and fair elections. They are a brazen, criminal attack on the United States Capitol, the seat of its government, federal personnel, and duly elected officials attempting to exercise the rule of law. Those who incited or perpetrated this violence, wanton destruction, and intimidation must be held accountable to the full extent of the law. As well, President Trump must be held accountable for his role in stoking and encouraging violence aimed at disrupting an electoral process and for his acts to subvert the peaceful and rightful transfer of power. President Trump’s utter lack of respect for the rule of law and shameless disregard for the safety of civilians cannot be tolerated. Time and again, law enforcement has used extreme force to suppress overwhelmingly peaceful demonstrators speaking up for racial justice. Yet yesterday, with President Trump’s encouragement, a violent mob was allowed to rampage through the halls of the U.S. Congress. These appalling events expose the systemic racism, injustice, and inequality in the U.S. system of justice and law enforcement. This dichotomy and the inexcusable lack of preparedness for what many anticipated would be a violence-prone riot must be investigated. We must confront and reckon with the United States’ shameful history of racism, and of tolerance for and enabling of white supremacy in the corridors of power and in the public discourse.

Tigray Crisis: Millions in Ethiopia At Risk

As the news cycle in the United States is dominated by the aftermath of the presidential election and the coronavirus pandemic, a humanitarian crisis is developing in Ethiopia. Since Prime Minister Abiy Ahmed’s election in 2018, the Tigray People’s Liberation Front (TPLF) have complained of unfair treatment with respect to corruption charges and removal from political appointments. These conflicts were compounded when the Ethiopian elections that were originally scheduled for August 2020 were postponed due to the coronavirus pandemic. The Tigray region responded by holding its own elections in September 2020, which PM Ahmed and his government deemed invalid. As a result, both sides came to see the other as governing illegally, and as tensions rose, the Tigray region withdrew its representatives from the federal government, and the federal government withheld funding for the Tigray region. On November 4th, the Ethiopian federal government alleged that an attack on a military camp had been carried out by the TPLF and, in retaliation, declared a state of emergency. PM Ahmed announced that the federal government would soon begin taking military action against the TPLF. On November 9th, according to Amnesty International, “likely hundreds” of civilians were killed in a massacre perpetrated by the TPLF, according to witnesses. The TPLF also began bombing the neighboring country of Eritrea, accusing it of supplying Ethiopia with soldiers and military supplies, an act that further destabilized the hostile peace between these two nations plagued by decades of conflict. Amid international calls to de-escalate the conflict to prevent outright civil war, military action continued, including air strikes and fighting on the ground. Internet and telephone communications were blocked by the federal government, adding to the difficulty of verifying information. Transportation to the Tigray region was disallowed, cutting off the region’s access to food and other important supplies. Within days, displaced people started pouring into neighboring Sudan by the thousands. As of November 24th, at least 40,000 displaced people had fled Ethiopia to Sudan, where 1 million refugees already reside. PM Ahmed continues to reject international calls for dialogue with the TPLF. The conflict is occurring in a complex context. Along with other parts of East Africa, Tigray is currently suffering from desert locust infestations, which damage crops, livestock, pastures, and rangelands that are crucial sources of food and income. The region faces continued threats of new swarms in the coming weeks. Additionally, Tigray is affected by flooding and threatened by the COVID-19 pandemic. The overflow of refugees, involvement of Eritrea, and diversion of troops from Somalia are all potential repercussions of this conflict that could destabilize an already volatile region. Limited access to the region for assistance from international aid groups and the United Nations is exacerbating these issues. A lack of fuel and food resources puts the greatest strain on the most vulnerable, including the 96,000 Eritrean refugees already residing in the Tigray region. The UN estimates that 1.1 million people will need aid in the coming months. The Columbia Human Rights Initiative & Asylum Clinic is an organization of medical students and faculty members at the Columbia University Vagelos College of Physicians and Surgeons based in New York, NY. Sources Al Jazeera. Ethiopia: Tigray leader confirms bombing Eritrean capital. Al Jazeera English. https://www.aljazeera.com/news/2020/11/15/rockets-fired-from-ethiopias-tigray-region-hit-eritrean-capital. Published November 15, 2020. Al Jazeera. Ethiopian parliament votes to cut ties with Tigray region leaders. Al Jazeera English. https://www.aljazeera.com/news/2020/10/7/ethiopia-parliament-votes-to-cut-ties-with-tigray-region-leaders. Published October 7, 2020. Al Jazeera. Ethiopian PM Abiy accuses TPLF of camp “attack”, vows response. Al Jazeera English. https://www.aljazeera.com/news/2020/11/4/pm-ahmed-vows-response-after-deadly-attack-in-northern-ethiopia. Published November 4, 2020. Amnesty International. Ethiopia: Investigation reveals evidence that scores of civilians were killed in massacre in Tigray state. https://www.amnesty.org/en/latest/news/2020/11/ethiopia-investigation-reveals-evidence-that-scores-of-civilians-were-killed-in-massacre-in-tigray-state/ %0D%0A %0D%0A. Daba ET, Wroughton L. Ethiopia sends troops into renegade northern province as long-simmering tensions explode. Washington Post. https://www.washingtonpost.com/world/africa/ethiopia-tigray-military-tplf/2020/11/04/3cd0f4a8-1e90-11eb-ad53-4c1fda49907d_story.html . Published November 4, 2020. International Committee of the Red Cross. Ethiopia: ICRC calls for respect of people’s lives and property amidst escalating tensions in Tigray and other regions in the country. https://www.icrc.org/en/document/ethiopia-icrc-calls-respect-peoples-lives-and-property-amidst-escalating-tensions-tigray. International Rescue Committee. What is happening in Ethiopia’s Tigray region? https://www.rescue.org/article/what-happening-ethiopias-tigray-region?fbclid=IwAR2O-_wf3DtKn3cG7bzUcQnyj0Bc1LJQkoAnJEVHYe5pcPDeMyMGig-X7IM . Marks S. Ethiopia Claims Victory in Tigray Conflict After Shelling Restive Region’s Capital. New York Times. https://www.nytimes.com/2020/11/28/world/africa/ethiopia-tigray-Mekelle-assault.html. Published November 28, 2020. Thomson Reuters. Ethopia’s Tigray conflict risks “spiralling out of control”: UN human rights chief. Canadian Broadcasting Company News. https://www.cbc.ca/news/world/ethoipia-tigray-sudan-refugees-1.5800527. Published November 13, 2020. United Nations High Commission for Refugees. Ethiopian refugee numbers in Sudan cross the 40,000 mark. https://www.unhcr.org/news/briefing/2020/11/5fbcccbf4/ethiopian-refugee-numbers-sudan-cross-40000-mark.html. United Nations High Commission for Refugees. Global Focus: Sudan. https://reporting.unhcr.org/sudan.

What the U.S. Election Means for Rural America

Disclaimer: Physicians for Human Rights is a non-partisan organization that works at the intersection of medicine, science, and law to forensically document human rights abuses, build capacity in local communities, and advocate for justice around the world. All posts about United States or international elections reflect the views of the individual author and not the organization. For the past six weeks, I have been in rural South Carolina doing a family medicine rotation. This town is what one would often think of as a classic rural American town. The only restaurants are fast-food chains – Bojangles, Subway, McDonald’s. The phone signal is so weak that, unless I am connected to WiFi, my phone is useless. Folks who live here own a lot of land and love to go deer hunting. Others live in old houses with a lot of extended family and not enough food. Many people are part of Native American tribes and live in reservation communities. Most are on Medicare or Medicaid or have no insurance at all. What I find most surprising is that, regardless of everyone’s living situation and background, they all love President Trump. According to them, he is saving America. Every other person has told me that the COVID-19 pandemic is an organized plan by Democrats to overthrow the government. Chances are high that, when I ask patients if they want the flu shot, they look at me like I am crazy. “Honey, do you want to kill me? The flu shot is what gives people the flu. I never get that.” At first, I was self-conscious and uncomfortable in these surroundings. Even the doctors I work with are dedicated Trump supporters. Considering the president's criticisms of the scientific and medical communities throughout the pandemic, despite our sacrifices for the American public, the juxtaposition is difficult to square. If politics come up, the pro-Trump energy is often so intense that I choose to stay quiet. One patient, though, changed my mind and helped me better process their viewpoints. Like most of our patients, she brought a big bag overflowing with her medication bottles. Recently, she had heard the president talking about how China brought the coronavirus to America, and she decided that taking her medications, which come from China, was too dangerous. She had completely stopped all of them, and no matter what I said to try to convince her otherwise, she refused to believe that they are safe and helpful. There are so many reasons that people cannot take their medicines, but conspiracy theories from the president should not be one of them. Why is President Trump able to connect to this community so strongly? Why do these patients and colleagues believe him and no one else? They know that he would like to make cuts to Medicare and Medicaid, but they simultaneously believe he is the only person looking out for them. Native American patients have heard his comments about minority groups, yet they pray he will be re-elected. Most of them don’t look down on immigrants, or think that families should be separated, or believe that women shouldn’t have rights over their bodies. At the same time, most have grown up in communities where abortion ostracizes you, religion and Church community bring you a family, and immigrants only exist in the abstract on the news. I have learned that I cannot justify my shock about their beliefs by simply attributing it to ignorance or lack of education. Rather, their core beliefs are often in direct conflict with each other, and like all humans, they have complex, non-linear, and occasionally illogical thoughts to process these conflicting beliefs. This election is sure to unravel more conflicting thoughts from people across the political spectrum. Take the chance to listen. Continue to work towards the things that you are passionate about. But in the process, we cannot lose our ability to connect with each other. Suffering and cruelty go beyond one president or one election. Problems in our society point to our failure as a country to work together over decades and generations. Regardless of what happens during this election and over the next four years, we cannot let one person take away our collective, intrinsic ability to do good. Veena Mehta is a third-year medical student at the Medical University of South Carolina and serves as the Regional Chapter Mentor for the PHR SAB's South and South Atlantic regions.

Nightmare on Peach Street: The Horrendous State of Georgia's Detention Centers

Located less than 10 miles outside the heart of Atlanta lies Clarkston, Georgia, a city celebrated for its ethnic diversity. Clarkston has been referred to as the “Ellis Island of the South,” and the “most diverse square mile in America.” It is a celebrated and welcoming reminder of progress. Yet, Clarkston lies in close proximity to some of the country’s most horrific immigration detention centers. Perhaps a reflection of the United States itself, the state of Georgia is home to a wide spectrum of beliefs, behaviors, and level of respect for human rights. There exists a tension between Georgia's two histories: one of deeply rooted racism and oppressive policies and one of the civil rights movement forged by Dr. Martin Luther King Jr. that inspired change. The latter continues today by activists like John Lewis and Stacey Abrams. While “Black Lives Matter” and “Hate Has No Place Here” signs line the streets of metro Atlanta, the region serves as just one piece of a largely divided puzzle and is far from indicative of the attitudes of Georgians as a whole. It is within this complex landscape that we see the conditions of the Georgia detention centers intersecting not only with politics, but also economics, and, importantly, health care. Follow the money and see where it goes... Sprinkled throughout the state are six immigration detention facilities: Stewart Detention Center, North Georgia Detention Center (NGDC), Irwin County Detention Center, Folkston ICE Processing Center, Robert A. Deyton Detention Facility, and Atlanta City Detention Center (ACDC). By comparison, there are seven immigration detention centers in the entire state of California, which is not only more than 2.5 times larger than Georgia, but also shares a border with Mexico. The Stewart, Irwin County, Folkston, Deyton, and North Georgia detention centers are run by private companies and remain fully operational today. Stewart Detention Center is the second largest male and trans-women detention center in the U.S. With 1,725 beds, it receives more transfers of individuals detained than almost any other facility and even some states. Called the “black hole of America's immigration system,” Stewart is located in Lumpkin, GA, a rural town located an hour outside of Atlanta with a population of 2,741, according to the 2010 census. By simple calculations, at full capacity, individuals detained at Stewart make up about 63% of Lumpkin’s population. Sadly, reporting after the 2010 census by Facing South found that immigrants were held in detention centers to be counted for the census before being deported out of the country. In 2012, Stewart County received 85 cents per inmate per day, which contributed to more than half of the county’s entire annual budget. Meanwhile, across the state, reporting in 2017 from the Atlanta Journal-Constitution showed that construction of the Folkston ICE Processing Center costs Georgian taxpayers $73.79 daily per bed, amounting to $116.7 million in expenses over the next five years. From a purely economic standpoint, the U.S. (already more than $23 trillion in debt) and, particularly, residents of Georgia cannot afford this expense. From a human rights perspective, we cannot afford to ignore these violations. Health care, even if detained, is a human right What the Georgia detention centers lack in fiscal responsibility, they make up for in immorality and indecency. A 2012 ACLU report on Georgia detention centers identifies a range of human rights violations at Stewart, Irwin, and ACDC, including, but not limited to, insufficient personal hygiene supplies, poor nutrition, and limited food options. In 2011, Stewart ran out of toothpaste and soap and had just three working showers for 58 individuals. The report is filled with accounts of sporadic and rushed mealtimes leaving many hungry and woefully malnutritioned. Meals at these facilities almost never contain any fruit and only rarely include green vegetables or protein. Many individuals detained lost large amounts of weight while in detention, including Grzegorz Kowalec, who lost an astonishing 68 pounds over the course of a year. According to Freedom for Immigrants, the top complaint filed from individuals in immigration detention centers was medical neglect and abuse. In September 2011, the assistant warden at Stewart admitted that the medical unit had had no physician on staff since August 2011, and a follow up in December of that year revealed that one had still not been hired. In addition, the ACLU of Georgia was informed by ICE that Stewart had been without a physician since August 2009, a period of almost two and half years, which is significantly longer than the standard previously set by the private owner of the detention center, Corrections Corporation of America. Furthermore, individuals in ICE facilities reported that requests for medical care were severely delayed and, in some cases, ignored completely. Angela Kelley was detained at Irwin and resorted to a six-day hunger strike in order to see a nurse after filing multiple requests for over a month to see a medical professional. Even when medical staff are available, it is rare that they speak the language of the individual or have an interpreter present for the encounter. On occasion, the medical neglect far exceeds limited access to medical care and constitutes medical abuse: "I feel like I'm going crazy....When I get upset, they just give me more medicine. I can't tell them I'm really upset or they just put me in a helmet and handcuffs for a few days. That's torture! I don't see anybody. I don't really care about anything. I just want to get out and get into a program that will help me." - Ermis Calderone, former detainee at Stewart Detention Center “The first six months I took the [HIV] medicine in Nigeria it didn’t work, but for the past three years with treatment my viral load was undetectable and my CD4 count was healthy. I spent one week here without medicine. In the second week, the lab drew blood and said my CD4 had dropped to 400 and my viral load was up. In the third week, the doctor asked questions about my medical history. In the fourth week, the lab did another blood test, but they didn’t answer anything I asked them, and I still had no medicine...A lot of people here are very sick and they still won’t take them to the hospital...I’m scared of what can happen to me...I’ve seen people die.” - Robert, former detainee at Atlanta City Detention Center. This kind of abuse and neglect resulted in 178 reported deaths in immigration centers between 2003 and 2018, three of which occurred in Georgia detention centers in 2018 alone. In more recent times, two detainees have died of COVID-19 while in ICE custody in Georgia as of March 2020, with alarming reports of failure to comply with any meaningful COVID-19 mandates. In September 2020, a whistleblower reported involuntary hysterectomies of women detained in Irwin County Detention Center. The shocking report of alleged forced sterilization follows a long history of unsafe, irresponsible, and abusive health care. We are quantitatively able to measure the death toll at the detention centers; however, we must also remember the rates of human suffering and long-term mental and physical health outcomes that former detainees must live with are just as important. These individuals are not just statistics - they are our neighbors, our patients, and our peers. It’s not all bad news! Well, maybe it is… Even so-called “wins” within the Georgia immigration landscape present their own challenges. In 2018, the city of Atlanta broke its contract with ICE, and the last individual detained was removed from ACDC. In 2019, Atlanta Mayor Keisha Bottom, signed historic legislation to re-purpose the ACDC site located in the heart of Atlanta. The Equity Center will replace the former state-run immigration detention center with the mission of “advancing racial and economic equity, promoting restorative justice, and investing in the well-being of individuals, families, and communities.” While the city taking a stand by removing its affiliation with a maligned ICE facility was a well-intentioned success (you can read more about human rights violations at ACDC in this Project South report), the word choice is important here: the individuals once at ACDC were removed, not released. Likely, they were removed to another detention center - one that is privately run, with potentially worse conditions, and farther from family, urban areas, and media hubs. Additionally, many detainees rely on nonprofits and organizations that can provide pro-bono resources to help them navigate the immigration landscape in Georgia. Unsurprisingly, the majority of these resources are located in and around metro Atlanta - far from the rural detention centers where they were likely moved it. So what? Although it is often medical neglect and abuse in the Georgia detention centers that remain at the forefront of our minds as healthcare providers, it is clear that the inhumane treatment does not stop at medical neglect. There is very little, if anything, about the centers that could be called “acceptable”, including the very fact that in this country we subject people to forced detention under the guise of preventing illegal immigration. The very nature of these facilities is criminal. While some may argue that the state of Georgia’s detention centers is solely an issue for politicians or lawyers to combat and that we, as healthcare providers, should “stay in our lane,” the terrible conditions and consequent negative health outcomes faced by those in detention are a violation of medical rights and, thus, human rights. As medical students and physicians, we are advocates, and the human beings in these detention centers are our patients—this is our lane. Nicole Lue is a second-year medical student at Emory University School of Medicine.

Mental Health Afflictions of Children in the Middle East

Amidst the COVID-19 pandemic and protests worldwide against racial injustice, one thing has not changed: the fact that armed conflict and instability continues to hang like an unrelenting cloud over the Middle East. This has had an impact not only on infrastructure, physical health, and survival, but also on the mental health of those who are fortunate enough to survive (or unfortunate to have to live through) the unending war and conflict, and resulting devastation. Armed conflicts have a devastating impact on the mental health of affected populations. Post‐traumatic stress disorder (PTSD) and depression are the most common mental disorders in the aftermath of war for both adults and children, occurring in at least one third of people directly exposed to traumatic war experiences. PTSD among Syrian refugee children has been so severe and unprecedented in magnitude, that it has escalated to the point where some mental health professionals have coined a new term for these particular cases of trauma: “human devastation syndrome”. Dr. M.K. Hamza, a Syrian neuropsychologist, uses this term as it aptly reflects the fact that the children’s devastation “is above and beyond what even soldiers are able to see in the war”, including “seeing dismantled human beings that used to be their parents, or their siblings”. In the Gaza Strip, 7 out of every 10 of evaluated adolescents have been found to meet the criteria for post-traumatic stress disorder (PTSD), with nearly 97.5% of these same adolescents displaying severe anxiety levels. A 2007 survey of Palestinian schoolchildren found that 80% of children witnessed shootings firsthand, with 10% exhibiting a depressive-like state, and 14.1% exhibiting emotional difficulties. Psychiatric patient admittances in Gaza have increased by 69% within the last two years, with increases in reported anxiety, depression, and suicidal thoughts and behaviors. A 2018 Save the Children survey in Iraq found that “43 per cent of children in the city of Mosul reported feeling grief always or a lot of the time” (Save the Children, 2018). Despite the widespread nature of anxiety, depression, and PTSD, much of the responsibility for remedying these emotional and psychological impacts has fallen to non-governmental organisations such as Medecins Sans Frontieres (MSF- Doctors without Borders), which has provided welfare and support to many Iraqis with mental health ailments. MSF advises that there are currently only four psychiatrists for every 1 million residents in Iraq, and even fewer professionals are trained in related mental health professions such as psychological counseling. As things stand, there are only four professionals currently looking after Syrian refugees in Iraq who must grapple with carrying out 70-100 counseling sessions per week with these individuals. Similarly, in Jordan, a country now hosting nearly 700,000 refugees, there are a total of 31 psychiatrists for the whole country, which is largely composed of refugees from Palestine, Iraq, and Syria. Lebanon and Turkey also have inordinate numbers of Syrian refugees who have fled the devastation within their own country. Unfortunately, most psychiatric professionals are strictly hospital-based and provide mainly biological care leaving no mental health professionals to address PTSD in these populations.

Add to that the situation in Yemen, home to the worst humanitarian crisis on earth, where hundreds of thousands have been killed, with millions suffering from malnutrition and preventable diseases such as cholera. It has been difficult to quantify and evaluate mental health there, but it is clear that the situation is especially dire. When you have children witnessing the deaths of their family members, or witnessing their loved ones withering away from starvation in front of their own eyes, it takes a massive psychological toll. Moreover, there has been a shortage of psychiatric specialists in Yemen since the start of the Saudi intervention. In January 2016, the WHO estimated that there were 40 psychiatric specialists in Yemen, most of whom were based in the capital, Sana’a. In December 2016, the director of the mental health program at the Ministry of Health suggested there were just 36 psychiatric specialists. Mental health is not integrated into the primary health care system, and many Yemenis are unable to access treatment when they first make contact with the healthcare system. Mental health in the COVID-19 Era On top of the devastation and mental health crisis, these populations have had to contend with the COVID-19 pandemic as well. In their dire state, to have to grapple with this condition only adds to the mental health catastrophe that they face. Since the pandemic and national lockdowns, the United Nations High Commissioner for Refugees (UNHCR) has documented alarming reports of increasing mental health issues among the many refugees in the Middle East and Northern Africa. In Lebanon, Libya, Yemen, and other countries in the Middle East, there have been spikes in suicide, domestic violence, insomnia, and depression.

To the credit of the UNHCR, they have been implementing a number of approaches to address these mental health issues. They are utilizing and training personnel in Psychological First Aid (PFA), an evidence-based approach to intervene for individuals in the immediate aftermath of disaster and terrorism to prevent the development of PTSD. For instance, in Iraqi refugee camps, trained community workers have provided PFA to primary healthcare staff, NGO workers, and community outreach volunteers. Furthermore, the UNHCR has created hotlines to receive and respond to psychological issues.

This is helping the situation, but more needs to be done to address the dearth of mental health professionals, as well as the root cause of the dire circumstances that have led to the resultant mental health catastrophe in the first place.

The cruel fact of the matter is that U.S. and Western foreign policy and intervention have played a big part in why the situation is what it is today. To quote award-winning Beirut-based journalist Robert Fisk of The Independent, “We always arrive with our tanks and our helicopters and our [armored] personnel carriers, and our soldiers, instead of arriving with our teachers, our educators, our doctors and our social carers.” From my position, I would like to emphasize doctors, and add on professionals from all spheres of health care, including mental health.

We must acknowledge the role of our country in perpetuating the catastrophe in that part of the world today. I can think of no better way than those in health care and mental health can get involved than through joining human rights organizations and offering their services to this part of the world. Moreover, we need to put pressure on our elected leaders to change their stance and approach on the Middle East of endless military intervention. We need our leaders to take a non-interventionist policy, ending our military occupation and interference with the affairs of other sovereign nations. All this has done is create a never-ending cycle of destruction and failed states.

Among other things, the current U.S. administration is openly supporting the Saudi-led intervention in Yemen which is creating the worst humanitarian catastrophe and resultant mental health crisis in the world. The U.S. has cut all funding to the United Nations Relief and Works Agency (UNRWA), the main organization sustaining the lives of Palestinian refugees in Gaza. These decisions are only going to make the situation and ensuing mental health catastrophe even worse. We need to make our voices heard, and to show not only solidarity, but also directly intervene and offer our services to address the needs of these people. It is the very least we, as Americans and Westerners, can do. Millions of lives depend on it. Racheed Mani is a third-year medical student at the Renaissance School of Medicine at Stony Brook University. He is also the founder of the PHR student chapter at his medical school.

The United States' Youth Detention System Poses Serious Threats to Health Care

There are over 43,00 youth currently held in juvenile detention and correctional facilities across the United States. Long before the COVID-19 crisis, the conditions of confinement in these facilities threatened the wellness and proper development of incarcerated youth. Today, with COVID-19 wreaking havoc on our country and the world, that threat has grown exponentially. Our communities have failed to adequately protect some of our most vulnerable youth, but we cannot continue to fall short. Typical conditions of juvenile detention and correctional facilities include, but are not limited to, inadequate access to proper educational and developmental programs, physical and emotional abuse, claustrophobic and unsanitary spaces, limited contact with family/support systems, and lack of adequate healthcare resources. Research has shown that these conditions lead to adverse physical, emotional, and mental health outcomes. During a pandemic, such adverse conditions are only exacerbated. Research by public health experts shows that incarcerated populations are among the most vulnerable during pandemics. Prisons and detention centers often act as epicenters for highly contagious viruses like COVID-19 due to extremely confined living quarters and unsanitary conditions. Behind bars, youth are not able to participate in proactive measures to keep themselves safe, such as social distancing, frequent hand washing, accessing personal protective equipment, or staying in sanitized spaces. Further, youth detention and correctional facilities are often unequipped to meet the medical needs of youth if an outbreak should occur. Lack of resources allotted for prison health, as well as various security policies, increase the likelihood for delays in both diagnosis and treatment of the disease. Once diagnosed, youth are unlikely to have the capacity to properly isolate themselves from other youth. Further, higher rates of chronic health conditions in incarcerated youth have the potential to lead to more serious complications of the virus. If staff become ill, it will be difficult to provide care and support to youth, and if lockdowns are utilized, they will only exacerbate the spread of the virus. In addition to the physical health threats this pandemic poses on incarcerated youth, there is a growing concern about mental and psychiatric stressors. We know there is an increased prevalence of adverse childhood experiences (ACE) among youth who are incarcerated. Outbreaks of the virus in detention facilities threaten to lead to further ACEs and exacerbate the effects of previous traumas. For example, many facilities are currently prohibiting visitations from family, legal representatives, and other community members, as well as canceling school and other regular programming, leading to further isolation and lack of social support. In several facilities, there are reports of children being locked in their rooms for more than 23 hours a day as a form of “isolation” to mitigate the spread of COVID-19, not much different from solitary confinement. Aside from the trauma of being isolated for this long, these actions may in turn lead to increased self-harm and suicidal ideation. Such circumstances jeopardize both short-term and long-term health outcomes for these youths. In such dire conditions, what can be done to help keep incarcerated youth safe? The medical community must join the fight to protect incarcerated youth alongside human rights organizations and family members. We can do this by urging our local government and boards of health to tackle the issue in a variety of ways including: Release youth who can be safely cared for in their home communities. Create transition plans for youth released from custody that ensure their basic needs are met. Within the constraints of public safety, reduce new admissions to juvenile detention & correctional facilities and increase the use of diversion strategies. Develop and publish COVID-19 response plans and ensure data regarding suspected and confirmed cases are publicly available. Ensure all staff members are trained on the implementation of the response plans. Ensure that youth and families are notified of suspected and confirmed cases in a timely manner. Ensure that appropriate access to medical and mental health prevention, treatment, and care is the norm. Provide emergency funding to expand community-based services and supports for youth diverted to or released from detention facilities. The COVID-19 pandemic is only highlighting problems that are deeply ingrained in the juvenile justice system. Highlighting and advocating for solutions during this time can lead to more long-term change. As healthcare professionals and medical students, we have an obligation to help prevent the injustices and adverse health outcomes of youth in the juvenile justice system. This issue is not new. Injustices have always existed, but there has never been a more urgent time to act than now. Chris Diaz is a fourth-year medical student at The Ohio State College of Medicine. If you would like to get more involved in the #FreeOurYouth initiative, you may contact him at christopher.diaz@osumc.edu. Sources: Akiyama MJ, et al. "Flattening the Curve for Incarcerated Populations - Covid-19 and Jails and Prisons." New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/ NEJMp2005687 Cullen K and Ndudom E. "Doctors Call for Releasing Youth from Secure Custody During COVID-19 Crisis." Juvenile Justice Information Exchange. https://jjie.org/2020/04/28/public-health-officials-call-for-releasing-youth-from-secure-custody-during-covid-19-crisis/ Kinner SA, et al. "Prisons and custodial settings are part of a comprehensive response to COVID-19." The Lancet. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(20)30058-X/fulltext Teplin LA, et al. "HIV and AIDS Risk Behaviors in Juvenile Detainees: Implications for Public Health Policy." American Journal of Public Health 93, no. 6 (June 2003): 906–12, https://doi.org/10.2105/AJPH.93.6.906; Committee on Adolescence, “Health Care for Youth in the Juvenile Justice System.” Fatos Kaba, et al. "Solitary Confinement and Risk of Self-Harm Among Jail Inmates." American Journal of Public Health 104, no. 3 (March 2014): 442–47, https://ajph.aphapublications.org/doi/ 10.2105/AJPH.2013.301742 Logan-Green P, et al. "Childhood Adversity among Court-Involved Youth: Heterogeneous Needs for Prevention and Treatment." 5 J. Juv. Justice 68 (2016). Yael Cannon & Dr. Andrew Hsi. "Disrupting the Path from Childhood Trauma to Juvenile Justice: An Upstream Health and Justice Approach." 43 Fordham Urb. L. J. 425 (2016). American Academy of Pediatrics. "Responding to the Needs of Youth Involved With the Justice System During the COVID-19 Pandemic." https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/responding-to-the-needs-of-youth-involved-with-the-justice-system--during-the-covid-19-pandemic/

Don't Separate Migrant Children from their Parents

As a medical trainee who works with children and families, I am encouraged by the order to release children who have been held for more than 20 days in the detention centers run by Immigration and Customs Enforcement (ICE) by July 17, as issued by Judge Dolly M. Gee of the United States District Court for the Central District of California. This order is critical in light of the insufficient measures put in place in detention centers to ensure that children and families are protected against COVID-19. Not only are families in these centers unable to practice the evidence-based social distancing that states and federal government agencies have promoted throughout this pandemic, but they also often lack access to masks, hand washing supplies, and cleaning supplies - basic necessities that are critical in the face of an unprecedented viral pandemic. While the decision by Judge Gee stating that ICE must work to release the children with “all deliberate speed” is a step in the right direction, either along with their parents or to suitable guardians with the consent of their parents, dire concerns remain that children may be separated from their parents in facilitating this release. Such a policy would ignore the overwhelming evidence of harm from detention and from separating children from their parents, which has been articulated by multiple American medical societies, including the American Academy of Pediatrics, which represents the voice of pediatricians across the U.S. Family separation can cause irreparable harm to children and is an act from which many families may never convalesce. As our government leaders are undoubtedly aware, multiple courts have ruled the practice unconstitutional. As medical trainees, we are obligated to safeguard the rights of children and share our concern regarding the safe release of children with their families. Releasing children is a positive step, but separating parents from children to facilitate this release will likely cause children and their families irreparable harm, not unlike the Zero Tolerance Policy that separated thousands of children from their parents. I have had the privilege of treating immigrants and asylum seekers and have witnessed firsthand the serious detriment that the threat of detention poses to the health and well-being of children. I have also had the honor of working alongside immigrant physicians who have stood by their neighbors to provide care to families across the U.S. during the COVID-19 pandemic. While I advocate for all children in this crisis, I recognize that refugee children are disproportionately at risk. In light of these recent events, I implore the leaders of the Department of Homeland Security and ICE to release children responsibly with their parents or to a suitable guardian in conjunction with the June 26, 2020 ruling by Judge Dolly M. Gee. Children should be released from ICE detention with their parents immediately. Families belong together. Rebecca Leff is a medical student at Ben Gurion University in Beer Sheva, Israel. She serves on the Physicians for Human Rights National Student Advisory Board’s Advocacy Committee. Please use this letter as a template by which to send a letter of your own to DHS and ICE leadership.

The Imprisonment of Pregnant Women under COVID-19

Andrea Circle Bear, an inmate imprisoned on account of drug charges, passed away after giving birth on Tuesday, April 28th while on a ventilator in federal custody in Texas. Her case sparked controversy worldwide in the discussion of reproductive justice and access to health services. As future physicians, the health care considerations of incarcerated individuals are vital to building stronger public health measures for all populations. When incarcerated women, especially those who are pregnant, are taken into custody, there are concerns about the emotional, physical, and mental wellbeing of themselves and their unborn child, urging for reform regarding care of the vulnerable prisoner. With both the mother’s and child’s lives in question, amending health care and prison legislation in the midst of COVID-19 is of utmost importance. New guidelines that protect the health and safety of pregnant women charged under federal law and ensure proper health standards in prisons to minimize contact with other inmates have become an emergency. As defenders of human rights, physicians and trainees hold a collective responsibility to advocate for the protection of these women. Speaking for those who lack a voice and for human rights to be upheld is every physician’s duty. In light of the COVID-19 pandemic, there is an increased need to reduce the prison population and protect incarcerated individuals, as viruses and diseases are easily spread within prisons. Although it is impossible to anticipate and prepare for every possible health threat posed to prisoners, Circle Bear’s arrest for a non-violent drug charge highlights the urgency of the current moment to protect vulnerable prisoners - especially non-violent offenders - as she was simultaneously pregnant and infected with SARS-CoV-2. Her prison’s conditions, rather than protecting prisoners by enforcing stricter social distancing measures and releasing smaller groups for exercise, recreation, and meals, unfortunately failed to meet the public health guidelines established by the Centers for Disease Control and Prevention (CDC), which contributed to widespread transmission within the prison. It is disturbing that, in the midst of a global health crisis, the United States federal prison system failed to protect its prisoners by releasing those charged with non-violent crimes or to ground them under house arrest. Pregnant prisoners are especially vulnerable, as they have limited access to timely adequate medical care and are often subject to abuse and mistreatment, inadequate diets lacking fruits and vegetables, and the placement of shackles that limit their mobility. Pregnant women have compared themselves to confined animals while being transported to and from their doctor’s appointments, fearing that they may trip or fall on their stomach and harm the child they are carrying. Circle Bear is not the only case of incarceration of a pregnant woman with COVID-19. In India, Safoora Zargar is currently behind bars due to her involvement in protests against a controversial citizenship law (the Citizenship Amendment Act of 2019), which gives refuge and citizenship only to non-Muslim immigrants from neighboring countries. The bill is discriminatory against Muslims, portraying them as infiltrators who have entered the country illegally. Safoora has been charged as a conspirator due to her association with the Jamia Coordination Committee (JCC) for inciting hatred and violence, attempted murder, and promoting enemity between different religious groups, even though these charges are largely unfounded. Upon arrest, her right and access to health care were compromised, as she was accused under the Unlawful Activities Prevention Act (UAPA), which makes it impossible for her to post bail. Furthermore, due to COVID-19 restrictions, she has been denied visitations by her husband and lawyer. Police who arrested her and sent her to an overcrowded prison during the pandemic failed to concern themselves with her unique circumstances. To date, she remains in an overcrowded prison with inadequate health precautions in place to protect her from disease. In light of these cases, we must consider alternative methods to safeguard the health of pregnant incarcerated individuals. Methods of home confinement for prisoners charged with non-violent crimes are necessary if we are to stop the spread of the virus. The benefits are clear: home confinement restructures incarceration, adheres to social distancing regulations, is cost-effective, and reduces the burden on overcrowded prisons. In particular, such measures benefit pregnant women as they are given comfort, safety, and access to health professionals from the enclosures of their own homes. With a tracking system in place to locate these women, authorities may also rest assured that the health and wellbeing of their prisoners is upheld while permitting them to serve for their transgressions. Additionally, for pregnant prisoners who may not be released, we as physicians and trainees must ensure that women have access to proper nutrition and that facilities set up proper hygiene protocols, including widespread personal protective equipment for both prisoners and prison employees. Prisons must make clear the rights entitled to pregnant women, must prohibit shackling during transportation, and must improve living conditions within their facilities to prevent institutional ignominy of these patients. For pregnant prisoners, there are two lives at stake, and their health rights must be especially protected in light of a deadly pandemic. More efforts are needed to reevaluate and reform the health care provided to incarcerated populations in light of COVID-19. As the cases of Circle Bear and Zarfar have taught us, pregnant women demand special attention and protections under these circumstances. As medical professionals and trainees, we are in a unique position to give voice to such patients and demand that higher quality care is afforded them through this pandemic. Leah Sarah Peer is a medical student at Saint James School of Medicine and a graduate of Concordia University, Specialization in Biology, Minor in Human Rights in Montreal, Quebec, Canada.

COVID-19 in Gaza: The Need to Lift the Blockade

As the world continues to battle the COVID-19 pandemic and cases and fatalities rise daily, these times call for essential geopolitical solidarity among even the most bitter of enemies. The United Nations has called for the suspension of all sanctions against the likes of Sudan, Venezuela, and Iran, countries for whom sanctions have dealt a severe blow to infrastructure, including in health care. One place that is ill-equipped to combat a pandemic, where the health system has been teetering on the edge for over a decade, is the besieged Gaza Strip, where a Gazan woman was recently confirmed as the first death in the region from the virus. Gaza, under the rule of the Islamic militant group Hamas since 2006, has been under a blockade imposed by Israel and Egypt for nearly 13 years. This period has been marred by deadly conflict between Israel and Hamas, in which thousands of Palestinians have been killed, buildings and facilities destroyed, and the allowance of essential medical supplies and food severely limited to the bare minimum needed for survival. 97% of the water in the Gaza Strip is unfit for human consumption, and electricity is severely limited to a few hours per day. While one cannot ignore the attacks and incendiary rhetoric of this intractable conflict, we must not lose sight of the fact that 70% of the nearly 2 million people in Gaza are refugees; half of the population are children. Gaza is also one of the most densely populated places on earth. The squalid conditions in its refugee camps, combined with its under-equipped hospitals and medical facilities, mean that a COVID-19 outbreak could be devastating. Its dense population means that “social distancing” is practically impossible. At the moment, there are only 2,500 beds and 87 ventilators available in Gaza. As highlighted by Palestinian-Canadian physician Dr. Tarek Loubani, many of these units are either already in use or woefully insufficient. It cannot manage the nightmare scenario of thousands of Gazans contracting the virus. Moreover, Israeli defense minister Naftali Bennett has recently halted COVID-19 testing in Gaza. Another issue here is the fact that Gaza’s limited access to electricity has meant that most hospitals are heavily dependent on generators. More importantly, much of the Gazan population already suffers from various medical conditions in part due to injuries sustained in the conflict, inadequate nutrition and contamination, and cancers for which access to treatment is extremely limited. The immunocompromised state of so many Gazans renders them even more susceptible to the lethality of the virus. We write this simply as a call to stress the dire health crisis that exists in Gaza, one that is sadly, in large part, manmade, manifesting from the blockade of the besieged enclave and devastation imparted by war.

Why is this issue relevant to us here in the United States? Well, the U.S. is the principal financial supporter of Israel and has thereby perpetuated the blockade of Gaza. It has provided billions of dollars of military assistance to Israel and vetoed virtually all U.N. resolutions holding Israel accountable for the blockade, thus enabling it to act with impunity in Gaza. Moreover, the recent decisions of the Trump administration to cut all funding to The UN Relief and Works Agency (UNRWA), a major provider of essential humanitarian and medical aid, has contributed further to the deterioration of the humanitarian crisis in Gaza. According to the International Committee of the Red Cross, the healthcare system in Gaza would likely not be able to cope with more than 100 to 150 serious COVID-19 cases at any one time. The situation is further compounded by the fact that, due to the blockade, many local medical professionals have left Gaza over the years in pursuit of opportunities elsewhere, meaning that medical manpower is also an issue. Furthermore, the Trump administration’s decision to cut all funding to UNRWA has meant that the cash-strapped organization has not been able to effectively carry out preventative health measures, such as sanitizing the refugee camps in the region. The World Health Organization (WHO) has indicated that Israel, while having allowed certain pharmaceuticals to enter Gaza, has either delayed or prevented the import of medical equipment, consumables, and spare parts. The Palestinian Authority (PA) also bears culpability here, as it has worsened this shortage of medical supplies over the years by cutting the transfer of medicine into Gaza in order to thwart its political rivals in Hamas.

While Hamas has imposed lockdown measures and quarantined individuals who have tested positive or have been in contact with those testing positive, these measures are not enough to avoid the nightmare scenario that could occur. The most vital action is that of Israel and Egypt to lift their blockade on Gaza and allow desperately needed medical equipment and supplies to enter the besieged enclave. The U.S. must act as a partner in these efforts to ensure that Israel and Egypt lift the blockade in these extraordinary circumstances. In 2018, the U.N. reiterated that the blockade “amounts to the collective punishment of the two million residents of Gaza, which is strictly prohibited under the Fourth Geneva Convention.” Israel needs to ensure that Palestinians in Gaza who contract COVID-19 can receive the appropriate care that is currently unavailable in the impoverished region. To the credit of various activist groups, such as the NGO Physicians for Human Rights (PHR) – Israel, there have been calls within Israel for its health ministry to provide assistance to medical authorities in Gaza, making it clear that, in light of the ongoing health crisis, Israel is responsible, by international law, to provide the requisite means of health care and treatment to the Health Ministry in Gaza. Moreover, Gazan medics have recently received training from their Israeli counterparts in Ashkelon, indicating some degree of cooperation between Israel and Hamas in quelling the virus.

However, the best means of preventing an absolute health catastrophe is to lift the blockade immediately. Security threats are often mentioned as the rationale behind the blockade, but permitting the passage of fundamental medical supplies would benefit all parties in the region. Palestinians, Egyptians, and Israelis, who live in such close geographical proximity to one another, would all benefit from such measures to prevent the epidemic from spreading from one community to the next in the blink of an eye. So far, there are over 50 confirmed cases in the Gaza Strip. The nightmare scenario has not yet been realized, but Gaza, now with a recent uptick in cases, is teetering on the precipice. This virus does not discriminate between Arabs and Jews, and the lifting of the blockade would provide a critical lifeline to individuals both within and around the Gaza Strip. Millions of lives depend on it. The Stony Brook PHR chapter is a collection of medical students based at the Renaissance School of Medicine at Stony Brook University on Long Island, NY.